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Investigation and
management of dry eyes
increased hyperosmolarity of the surface,
which causes rapid tear break up and
increased shearing forces, due to reduced
tear volume and reduced mucins at the
ocular surface, resulting in inflammation
ANTERIOR EYE AND OCULOPLASTICS PART 4 C-19306 O/D
44
hypersensitivity of the nerve endings.
Amit Patel, MB BCh, FRCOphth
When
Sunil Shah, MBBS, FRCOphth, FRCS(Ed), FBCLA
thorough
The International Dry
is
Eye Workshop (DEWS) defines dry eyes as “a
multifactorial disease of the tears and ocular surface that results in symptoms
of discomfort, visual disturbance, and tear film instability with potential
damage to the ocular surface. It is accompanied by increased osmolarity of the
27/07/12 CET
at the ocular surface and ultimately
tear film and inflammation of the ocular surface”. Dry eyes can have a profound
effect on a patient’s comfort, vision and quality of life. Accurate diagnosis and
classification of its severity is, therefore, important in developing an effective
treatment plan, and this article discusses the optimal optometric approach.
diagnosing
history
paramount
dry
from
and
eye,
the
a
patient
must
include:
•Frequency, severity and variation of
symptoms
•Medical history (eg rheumatoid arthritis,
thyroid dysfunction)
•Drug history (eg use of systemic
antihistamines)
•Environmental factors (eg exposure to
air conditioning, contact lens wear)
•Previous ocular surgery (eg refractive
surgery)
Incidence
care
Dry eye has long been recognised as a
influenced their decision to use these
common, and often chronic problem,
• 63% of adults who use OTC eye
professional
Several questionnaires are available for
symptoms
dry eye evaluation in clinical practice
Dry Eye Survey1 suggests the condition
state that these are only “somewhat”
(Table 1). While these are not a substitute
may be more prevalent than previously
or
for history-taking, they serve as a useful
survey
found
that:
• 48% of adults experience one or
“not
at
their
Subjective tests
drops
The
manage
pharmacist
particularly in older adults. The Allergan
believed.
to
or
•Lubricant use and frequency
all”
successful.
tool to detect the presence of dry eyes and
Diagnosis
to evaluate the effects of therapy. Such
vary
questionnaires may be used in optometric
considerably and may not always correlate
practice prior to suggesting treatment and
of
with the diagnostic test results and clinical
may also empower patients to monitor their
symptoms
signs. The symptoms reported by patients
symptoms and adjust their own therapy.
• 48% of adults who use over the
include a foreign body sensation, burning,
counter (OTC) eye drops to manage
stinging, grittiness and blurred vision,
Objective tests
their symptoms state that their eye
particularly notable when performing
These
more dry eye symptom(s) regularly
• 43% of adults experience difficulty with
reading
their
as
dry
a
eye
result
Symptoms
of
dry
Questionnaire
Number of
questions
Source
Ocular surface disease index
12
Schiffman et al.2
McMonnies dry eye
questionnaire
14
McMonnies and Ho
Dry eye questionnaire
23
CANDEES
13
3
Begley et al.
4
Doughty et al.5
Table 1
Dry eye questionnaires for subjective evaluation of symptoms
eyes
can
tests
evaluate
the
concentrated
(quantity,
quality
and
activities
and
of
ocular
and/
state
the
tears
stability)
surface.
or when in dry
Tear quantity is evaluated using the
atmospheres.
Schirmer Type 1 test and tear meniscus
The
cause
height (TMH). The Schirmer type 1 test
is unknown, but
(without anaesthetic) involves using a
could be due to
5x35mm strip of filter paper, which is
the
exact
of
anchored to the lower fornix and kept in
nociceptive
place for five minutes, at which point the
nerve endings on
length of wetting is measured. This measures
the corneal surface.
the basal and reflex tear production.
The nerve endings
Less than 5mm of wetting is considered
are stimulated by
diagnostic of aqueous tear deficiency.
the
activation
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The Schirmer Type 2 test is performed
lamp beam with cobalt blue filter looking
established,
after instilling a drop of anaesthetic and
for evaporation of the tear film, which is
will allow appropriate treatment to be
measures only the basal tear secretion; the
characterised by the appearance of black
commenced. Dry eyes may be broadly
presence of anaesthesia will prevent reflex
spots. The tear film break-up time (TBUT)
classified into aqueous deficiency dry
tearing. There is evidence to suggest that
is the interval between the last blink and
eye (ADDE) or evaporative dry eye (EDE)
the Type 2 test produces greater variability
first appearance of a black spot. An average
(Figure 1). The above diagnostic tests may
and thus the Type 1 test is most commonly
of three measurements is taken and a TBUT
help determine which group the patient
performed and utilised for diagnosis of
of ≤10 seconds is indicative of dry eyes.
falls into, eg a reduced Schirmer’s test is
dry eyes.6 The TMH is a non-invasive
The ocular surface evaluation includes
indicative of ADDE, and reduced TBUT
evaluation performed using the slit lamp.
assessment of the lid margin, conjunctiva
is indicative of EDE. In reality, however,
A height of <0.2mm is associated with tear
and cornea, notably grading these for
both ADDE and EDE may co-exist.
deficiency. In patients with dry eyes, the
signs of dryness. The Oxford ocular
Furthermore, both may give rise to similar
tear meniscus is frequently reduced and
surface grading system may be used to
signs and symptoms. It is, therefore,
has an irregular edge along the lid margin.
document the location and severity of
important to determine the individual
surface damage.
This is usually done
components causing the dry eyes from the
by assessing fluorescein and lissamine
patient history, diagnostic tests, and ocular
the osmolarity. A small sample is taken
from the lower tear meniscus, such that
reflex lacrimation is not induced. Using
a microchip, the electrical conductivity
of the tear sample is measured and
this indicates the concentration of tear
constituents; hyperosmolarity of the tear
film is suggestive of dry eye due to reduced
tear quality. One such device that indirectly
measures tear osmolarity is the TearLab
(TearLab Corp., San Diego, USA). A result
of >316 mOsm/l is indicative of dry eyes.
Tear film stability is assessed after
instillation of fluorescein into the lower
fornix and the patient is asked to blink
7
green staining of the bulbar conjunctiva
and cornea. Lissamine green stains dead
or devitalised cells, which occur as a
result of dry eyes. Conjunctival injection
is also noted and graded. Grading the
severity of surface damage, usually on a
scale of: 1 (none), 2 (mild), 3 (moderate)
and 4 (severe), is useful for monitoring
treatment effectiveness. Various other tests
are also available, including evaluation
of
lysozyme,
lactoferrin
and
matrix
metalloproteinase-9 (MMP-9) levels in the
tears, while impression cytology, brush
cytology and lipid layer interferometry
its
cause
surface evaluation, so that treatment can
be targeted. For example, blepharitis
is a common cause of dry eyes and the
severity may not always correlate with the
symptoms. It is characterised by crusting
around the eyelashes, frothy tears, lid
margin irregularity, vascular engorgement,
plugging of the meibomian gland openings
and displacement of the mucocutaneous
junction. Grading the degree of blepharitis
and
conducting
diagnostic
tests
of
tear quality can then allow treatment
to be targeted to alleviate symptoms.
(LipiView, TearScience Inc., Morrisville,
Management
North Carolina, USA) may also be
Management of dry eye disease is aimed at
since drops may lead to excessive dying of
employed. The latter allows practitioners
the various components which contribute
the tears and affect the quality of the test.
to obtain digital images of the tear film
to the symptoms. A very important,
The tear film is scanned with a broad slit
and grade it within about three minutes.
and sometimes underrated, element of
several times and then to refrain from doing
so; a moistened fluorescein strip is preferred,
2
management is an explanation about
the
the cause(s), its aetiology and treatment,
cut-off
with emphasis that in the vast majority
these
of cases this is not a curable disease.
tests,
Simple measures relate to the external
3
environment, such as increasing humidity
Table
Diagnostic test
Cut-off value for clinical dry eye
summarises
diagnostic
Schirmer Type 1
≤ 5 mm wetting in 5 minutes
Tear break up time (TBUT)
≤ 10 seconds
Tear meniscus height
≤ 0.2 mm
Fluorescein staining
> 3 (scale 0-15)
Lissamine green staining
> 3 (scale 0-15)
Tear osmolarity
> 316 mOsm/l
Table 2
Cut-off values diagnostic of dry eyes for simple clinical tests
values
for
diagnostic
while
Table
indicates the grading
and
of different severities
especially in windy conditions (in very
of
severe dry eye, wearing swimming goggles
dry
eyes.
wearing
protective
spectacles,
has been shown to provide symptomatic
Causes
relief). A review of systemic drugs is
Once the diagnosis
worthwhile as some drugs, eg beta-blockers
and
of
and some psychotropic drugs (among
dry eyes has been
others), are known to cause dry eye and
severity
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27/07/12 CET
Tear quality is measured by assessing
ascertaining
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Discomfort, severity and Mild and/or episodic;
frequency
occurs under
environmental stress
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4
2
3
4*
Moderate, episodic, or
chronic; stress or no stress
Severe and/or frequent or
constant; without stress
Severe and/or disabling
and constant
Visual symptoms
None or episodic with mild Annoying and/or activity
limiting; episodic
fatigue
Annoying, chronic and/or
constant; limiting activity
Constant and/or possibly
disabling
Conjunctival injection
None to mild
None to mild
None to mild
Mild to severe
Conjunctival staining
None to mild
Variable
Moderate to severe
Severe
Corneal staining
(severity/location)
None to mild
Variable
Severe central
Severe punctate erosions
Corneal/tear signs
None to mild
Mild debris, reduced TMH
Filamentary keratitis,
mucous clumping, tear
debris
Filamentary keratitis,
mucous clumping,
increased tear debris,
ulceration
Lid/meibomian glands
MGD variably present
MGD variably present
Frequent
Trichiasis, keratinisation,
symblepharon
TBUT (sec)
Variable
≤ 10
≤5
Immediate
Schirmer score
(mm/5mins)
Variable
≤ 10
≤5
≤2
Table 3
Dry eye severity grading scheme.8 TMH = Tear meniscus height; MGD = Meibomian gland dysfunction; TBUT = Tear break-up time. *Must have signs AND
symptoms
there may be an option to change them.
Table
4
summarises
the
However, it should be noted that most
been no large-scale, masked, comparative
main
‘artificial tears’ do not actually mimic the
clinical trials to evaluate the wide variety
approaches which can be used to treat dry
composition of natural tears and instead
of ocular lubricants and the majority of
eye according to the severity. These are
contain active ingredients (eg demulcents,
prescribing remains empirical or based
discussed in turn in the sections below.
emulsifiers, surfactants, and viscosity
on patient self-reported preferences. The
agents) and inactive additives (eg castor
DEWS study9 reported that, although
Lubrication
oil and guar in Systane). However, it is
ocular lubricants provide some protection
The mainstay of dry eye treatment is
very difficult to prove that the active
of the ocular surface epithelium, there is
tear supplementation with lubricants.
ingredient is indeed ‘active’. There have
no evidence to suggest that any agent is
superior to another. Most clinical trials
document some improvement but not
resolution of subjective symptoms of dry
eye and in some objective parameters.
However, the improvements noted are
not necessarily any better than those seen
with non-preserved artificial lubricants.
The elimination of preservatives and
the development of newer, less toxic,
preservatives have made ocular lubricants
better tolerated by patients. Indeed,
the ideal ‘artificial tears’ should be
isotonic, preservative-free, contain the
Figure 1
Classification of dry eye
electrolyte composition of natural tears
and have a mechanism that increases tear
retention time. The main variables in the
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formulation of ‘artificial tears’ are the
Nutrition
regulations surrounding blood products,
concentration and choice of electrolytes,
Omega-3 fish oils have been shown
and therefore is not widely available.
the osmolarity and the type of viscosity/
to help with dry eye syndrome,
polymeric system, the presence (or
either
absence)
preparations
type
of
preservative.
as
commercially
or
as
available
flaxseed
oil.10
Ultimately, the clinician has to decide
Punctal plugs
Punctal plugs are a simple and effective
solution to treat dry eyes that have not
on the severity of the dry eye and
Antibiotics
advise the patient on their options.
Oral
(eg
above. Patients with lid margin disease
Mild dry eye may not need any
doxycycline and minocycline) have
and ocular surface inflammation must
treatment. If lubrication is needed,
proven beneficial in cases of advanced
have adequate treatment for this prior
then hypromellose is cost effective. But
meibomian
dysfunction
to considering the use of punctal plugs,
advice as to frequency of use and long-
(MGD).11 It is believed that these
otherwise there will be retention of
term maintenance is essential. A very
drugs
pro-inflammatory
common problem is that frequency of
bacterial lipases, which serve to alter
on
use is inappropriately low and therefore
the consistency of the meibomian
enhance damage to the ocular surface,
patients feel that the therapy is ineffective.
oils. In addition to their antibacterial
accelerate
For moderate to severe dry eye, it is
action, tetracyclines are recognised
therefore
appropriate to suggest more viscous
to
anti-inflammatory
Absorbable plugs are made from collagen
preparations such as Viscotears, Gel
agents, inhibiting the expression of
or polymers and last for a few weeks,
Tears or some of the newer preparations
matrix metalloproteinases and other
or months, prior to disintegrating. They
such as Optive, Systane (Systane Ultra),
cytokines. Therapeutic effects may
are useful for short-term occlusion, eg
Theratears or one of numerous hyaluronic
be seen with low doses (typically
post-refractive surgery or as a trial to
acid preparations. In addition, one should
50-100mg
Topical
assess their effectiveness. Non-absorbable
consider a preservative-free variety if
azithromycin has recently been shown
plugs are generally made from silicone
using contact lenses or a high frequency of
to be effective in the treatment of
and
instillation is required, eg Celluvisc 1% or
blepharitis.
these
Vismed (some patients prefer Refresh or
also exhibits anti-inflammatory effects,
Plugs are available in various diameters
Celluvisc 0.5% particularly with contact
in addition to its antibacterial action.
ranging from 0.2mm to 1.0mm. It is
responded to simple measures described
tetracycline
gland
inhibit
be
derivatives
the
potent
once
12
production
daily).
of
Like the tetracyclines, it
lenses in situ). Some patients also benefit
the
ocular
the
components
surface,
disease
produce
although
can
tear
which
process,
greater
removed
may
and
discomfort.
considered
be
‘permanent’
if
required.
important to select the correct size, as
from night time ointments eg Simple
Anti-inflammatory medication
large plugs may be difficult to insert, may
Eye Ointment, Lacrilube and VitA-Pos.
Dry eye disease has a significant
sit proud and irritate the ocular surface
inflammatory component, therefore
or fall off. Plugs which are smaller than
Lid hygiene
both topical steroids and topical
the punctal opening may migrate into the
Blepharitis is one of the commonest
cyclosporine
A
canaliculus and prove difficult to remove.
causes of dry eyes and eye lid hygiene
breaking
inflammatory
is the mainstay treatment. Scrubbing the
Dosage
base of the lash follicles with a cotton
severity and should be assessed in
•Smart Plug (Medennium Inc., Irvine,
bud dipped in dilute baby shampoo/
conjunction with all other measures.
California, USA). This is a temperature-
sodium bicarbonate solution, or dilute
However, the preferred formulation
sensitive
tea tree oil, is effective, as are a variety
for cyclosporine A is an emulsion,
thermodynamic acrylic polymer. It is
of commercially available lid wipes. For
which is not available in the UK yet,
thin and rigid (10.0mm long and 0.4mm
meibomitis (posterior blepharitis), hot
except from international pharmacies.
in diameter) at room temperature and
the
depends
are
on
useful
the
in
cycle.
disease
New
of
innovative
punctal
plug
plugs
fabricated
designs
include:
from
a
when inserted into a tear duct, the body
compresses or commercial units like the
‘Eye Bag’ help to soften the inspissated
Autologous serum
temperature shortens and expands it,
oils within the meibomian glands. This
Autologous serum drops derived from
transforming it into a soft gel-like glue which
is followed by gentle massage of the
the patient’s own blood have been
fills the punctal space. Unlike traditional
eyelids to express the oils. Selective
shown to be highly effective in cases
plugs, no part of the Smart Plug lies above
gland expression or cannulation may
of severe dry eye.13 However, it is
the surface of the eyelid after insertion
also be performed to unblock the glands.
costly and difficult to obtain due to the
and it is therefore instantly comfortable.
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DRY EYE SEVERITY LEVELS
1
2
3
4*
• Education and Environmental/
If Level 1 treatments are
If Level 2 treatments are
If Level 3 treatments are
inadequate, add:
inadequate, add:
inadequate, add:
• Anti-inflammatories
• Autologous Serum
• Systemic anti-inflammatory
Dietary modifications
• Elimination of offending
systemic medications
48
• Tetracyclines (for meibomitis, acne • Contact lenses
• Artificial tear substitutes, gels/
rosacea)
ointments
• Eye lid therapy
agents
• Permanent punctal occlusion
• Surgery (lid surgery,
• Punctal plugs
tarsorrhaphy; mucus
• Secretogogues
membrane, salivary gland,
• Moisture chamber spectacles
amniotic membrane
27/07/12 CET
transplantation)
Table 4
Treatment recommendations for dry eye by severity of the disease. Modified from the International Task Force Guidelines for Dry Eye.8
Other measures
level 2 severity of dry eye who are non-
This
Other measures for the treatment of dry
respondent
is a ‘one size fits all’ plug made
eye include increasing room humidity
with levels 3 and 4 severity should also
of
(eg
be considered for referral to the HES.
•FormFit
Plug
Glendora,
California,
hydrogel.
(Oasis
It
Medical,
USA).
hydrates
after
commercially
available
radiator
to
treatment
and
those
insertion to fill the punctal space.
humidifiers), wearing swimming goggles to
•Eagle
Plugs
retain moisture, moisture release eyewear,
About the authors
(EagleVision Inc, Memphis, Tennessee,
and surgical options including tarsorrhaphy
Mr
USA). These are perforated plugs which
and salivary gland auto-transplantation.
ophthalmologist at the Heart of England
Flow
Controller
are useful in patients who experience
Amit
Patel
is
a
consultant
NHS Trust and Midland Eye Institute in
improvement with plugs, but where
When to refer
full occlusion results in epiphora.
The initial management of dry eye does not
in
necessarily require referral to the hospital
surgery. He is a treasurer of the British
Other indications
eye service (HES). In fact, it could be
Society for Refractive Surgery (BSRS)
Various factors may result in poor patient
argued that primary care practitioners are
and a council member of the Medical
compliance in the use of drops, eg on the
better placed to provide this management
Contact
grounds of cost, dementia, poor vision,
than the HES, as they can recommend any
Association
or arthritis preventing adequate control
one of several ocular lubrication products
Shah is a consultant ophthalmologist at
of the bottle. These patients may benefit
available and even attempt the fitting of
the Midland Eye Institute, Birmingham
from punctal occlusion and may also
punctal plugs. Indeed, the Allergan Dry Eye
and Midland Eye Centre, and honorary
benefit from residual longer retention
Survey1 showed that eye care professionals
consultant at Birmingham Children’s
of any other therapeutic drops that they
influenced a patient’s decision to use OTC
Hospital.
may be prescribed (eg for glaucoma).
drops in a significant proportion of people.
professor at The University of Ulster and
People who experience dry eye as a result
It is the experience of the authors that
visiting professor at Aston University,
of contact lens wear may also benefit from
most patients seen in external eye disease
Birmingham. He specialises in complex
punctal plugs, provided that the lens fit
clinics are not using lubrication more than
corneal and refractive surgery. Professor
is good, they are using adequate wetting
three times daily and are intermittent in
Shah is past president of the BSRS and
solutions, and exercise good lens hygiene.
their compliance (as admitted by patients).
a specialist advisor to the National
Other
punctal
In cases where the aetiology is in doubt, the
Institute
occlusion may yield some benefit include
patient is symptomatic despite frequent
corneal infiltrates, corneal abrasions,
use of lubrication (and compliance is
References
recurrent corneal erosions, filamentary
good) or there is concern about permanent
See
keratitis,
keratitis,
corneal damage, then onward referral
Click on the article title and then
trachoma and neurotrophic keratopathy.
to the HES is appropriate. Patients with
on
conditions
superior
where
limbic
Birmingham. He has a special interest
corneal,
cataract
Lens
and
and
Ocular
(MCLOSA).
He
for
is
refractive
also
Clinical
Surface
Prof
an
Sunil
honorary
Excellence.
www.optometry.co.uk/clinical.
‘references’
to
download.
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Module questions Course code: C-19306 O/D (P44-48)
54
1. Which of the following is NOT likely to cause dry eyes?
a) Systemic antihistamines
b) Increasing age
c) Previous laser refractive surgery
d) Frequent preservative free lubrication
4. What is the MOST appropriate first line treatment for dry eyes?
a) Artificial tear substitutes
b) Autologous serum eye drops
c) Vitamin A therapy
d) Tarsorrhaphy
2. Which of the following signs is NOT associated with dry eyes?
a) Congestion of conjunctival vessels
b) Filamentary keratitis
c) Superficial punctate corneal erosions
d) Cells in the anterior chamber
5. Which of the following statements regarding treatment of dry eyes is
TRUE?
a) Tetracyclines may be effective in treating meibomian gland dysfunction
b) Preservative-free medication may exacerbate symptoms of dry eyes
c) Dietary modification is not effective for treating dry eyes
d) Autologous serum carries no risk as it is derived from the patient’s own blood
27/07/12 CET
3. Which of the following tests may be used in the diagnosis of dry eyes?
a) Schirmers Type 1 and 2
b) Tear osmolarity
c) Fluorescein and lissamine dye staining
d) All of the above
6. Which of the following statements about punctal plugs is TRUE?
a) They are used as a last resort in the treatment of dry eyes
b) They are only placed in the lower eyelid punctae
c)They can cause irritation of the ocular surface if not fitted correctly
d) They are a first choice treatment for dry eyes caused by blepharitis
Module questions Course code: C-19309 O/D
1. Which of the following is a common feature of cluster headaches?
a) Bilateral eye pain
b) Generalised headache
c) Diplopia
d) Red and watery eye
2. What should you do if a 75-year-old man develops an inferior visual field
defect and complains of headaches?
a) Enquire about scalp tenderness, jaw pain and loss of weight or malaise
b) Perform fixation disparity testing and prescribe the full amount of prism
c) Refer him routinely to ophthalmology for further testing (including blood tests)
d) Reassure the patient that the headaches are likely to be migraines
3. Which of the following is NOT a common feature of carotid artery
dissection?
a) Unilateral limb weakness
b) Visual field loss
c) Colour vision defects
d) Horner’s syndrome
4. Which of the following is most likely to be TRUE for a 42-year-old
overweight woman who complains of recent onset diplopia and severe head
pain?
a) She is likely to have a sixth nerve palsy which warrants correction with
prisms
b) She is likely to have papilloedema and should be referred as an emergency
c)There will be no other signs or symptom associated with this condition
d) The underlying condition is likely to be benign and no further action is
required
5. Which of the following is TRUE for a 35-year-old man who develops
amaurosis fugax and neck pain on the left side, one week after a
whiplash injury?
a) He is likely to develop sudden onset occipital headaches
b) He should be referred routinely to ophthalmology
c) There could be a left Horner’s syndrome
d) A visual field defect is unlikely to be present
6. Which of the following is MOST consistent with a headache due to
refractive error or heterotropia?
a) Thunderclap headache, which changes with different posture
b) Headache worse in the morning, often waking up the patient
c) Unilateral headache or pain around the eye with conjunctival redness and
lacrimation
d) Mild to moderate chronic / recurrent headache, worse in the evening,
relieved by painkillers
Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates